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Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less

CPT4 code

Name of the Procedure:

Simple Repair of Superficial Wounds of Scalp, Neck, Axillae, External Genitalia, Trunk, and/or Extremities (including Hands and Feet); 2.5 cm or Less

Summary

This procedure involves the simple repair of superficial wounds located on various parts of the body, including the scalp, neck, axillae (armpits), external genitalia, trunk, hands, and feet. The repair is carried out on wounds that are 2.5 centimeters or less in length.

Purpose

The procedure aims to close and heal minor superficial wounds to prevent infection, stop bleeding, and promote proper wound healing. It helps restore the integrity of the skin and minimize scarring.

Indications

  • Presence of small, superficial cuts or lacerations (2.5 cm or less) on the scalp, neck, axillae, external genitalia, trunk, hands, or feet.
  • Wounds that require professional medical repair to ensure proper healing.
  • Superficial wounds that are not heavily contaminated or deeply penetrating.

Preparation

  • The patient should clean the wound area with soap and water and keep it covered with a sterile dressing until the procedure.
  • No specific fasting or medication adjustments are typically required.
  • The healthcare provider may assess the wound and clean it further before repair.

Procedure Description

  1. The area around the wound is cleaned and disinfected.
  2. Local anesthesia is administered to numb the wound area, ensuring the patient does not feel pain.
  3. The wound edges are aligned and closed using sutures (stitches), surgical tape, or tissue adhesive, depending on the specific wound characteristics.
  4. A sterile dressing is applied to protect the repaired wound.

Duration

The procedure typically takes about 15 to 30 minutes, depending on the complexity and location of the wound.

Setting

The procedure is usually performed in an outpatient setting, such as a doctor's office, clinic, or emergency room.

Personnel

  • A physician, nurse practitioner, or physician assistant usually performs the procedure.
  • A nurse may assist by preparing the wound and providing follow-up care instructions.

Risks and Complications

  • Infection
  • Scarring
  • Allergic reaction to anesthesia
  • Minor bleeding
  • Rarely, wound dehiscence (reopening of the wound)

Benefits

  • Prompt wound closure
  • Reduced risk of infection
  • Effective bleeding control
  • Enhanced healing process
  • Minimization of scarring

Recovery

  • Keep the wound clean and dry.
  • Follow the healthcare provider’s instructions for wound care, including changing dressings and monitoring for signs of infection.
  • Avoid strenuous activities that may stress the wound area.
  • Sutures are usually removed within 5 to 10 days, depending on the location and healing progress.

Alternatives

  • Allowing the wound to heal by secondary intention (natural healing without suturing), though this may increase healing time and risk of infection.
  • Use of adhesive bandages or strips if the wound is very minor.
  • Pros and cons of alternatives will vary based on wound type and patient health.

Patient Experience

  • Patients may feel a slight pinch or sting when local anesthesia is administered.
  • The procedure itself is generally painless due to the anesthesia.
  • Mild discomfort or throbbing may be experienced as the anesthesia wears off, but over-the-counter pain relievers can help manage this.
  • Immediate post-procedure care focuses on keeping the area clean and dry to promote healing and prevent infection.

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